Neuro SAQ Flashcards
A middle-aged woman went to Japan, and she had mild flu-like symptoms during the trip. 2 weeks later she developed fever, confusion and speech problems. Physical examination revealed four limbs with normal power, no focal neurological deficits. History of depression, asthma, severe eczema, iatrogenic adrenal insufficiency.
1. Most likely dx and possible ddx
Plain CT show hypodensity over left side, sulcal effacement, obliteration temporal horn of lateral ventricle. Contrast MRI confirm same finding, and an additional area over right side, contrast enhancing over temporal area.
2. What specific investigation and treatment do you want to do. Briefly describe rationale
Suddenly deteriorate, left eye ptosis and abducted, right hemiparesis, CT showed same picture but with more extensive involvement.
3. what happened and what is your management
- Viral encephalitis, metabolic encephalopathy, autoimmune/post infective encephalitis, addisonian crisis, other infectious causes (bacterial, TB, fungal)
- Blood for viral PCR
CSF for differential cell count, protein, glucose
CSF for PCR HSV1/2, VZV, enterovirus, IgM JE
NPA x respiratory panel
EEG
IV acyclovir - Cerebral edema causing raised ICP and uncal herniation, ipsilateral CN3 palsy and contralateral cerebral peduncle compression.
ICP management: IV acyclovir (if suspect viral), elevate head, optimize BP and ventilation, seizure control, IV mannitol, consult neurosurg
An old gentleman presented with tremor that is worse when watching TV, slowing of movement
PE: tremors worsen when he puts his hand on his lap, persistent glabellar tap
1. Most likely dx
2. 4 core features for dx
3. Name 2 classes of drugs that would worsen his symptoms+ cognitive functions
4. Name 2 common ddx for cause
- Parkinsons disease
- Tremor, rigidity, bradykinesia, postural instability
- Anticholinergics, sedatives. 1st gen antipsychotic, antiepileptic, antiemetic, L-dopa
- Multiple system atrophy, Lewy body dementia, Drug induced Parkinsonism, Vascular parkinsonism
A young woman works in the restaurant had a sore throat 2 weeks ago. She developed pins and needle numbness first at feet then at fingers and hands. Lower limbs weakness the morning of admission. Physical examination revealed hyporeflexia of upper limb, lower limb knee jerk and ankle jerk absent. Upper limb normal power, lower limb 4/5 power. ?Mild loss of pin-prick sensation over limbs
1. What is the most likely diagnosis
2. What Ix to do?
3. Describe Mx and 2 mx issues
- GBS/AIDP
- LP for protein, glucose, cell count and differential for albuminocytologic dissociation
Nerve conduction study: demyelinating pattern (low SNAP and CMAP in AIDP)
Nerve biopsy (differentiate axonal, inflammatory, demyelinating)
Antiganglioside antibodies: GM1b, GQ1b (Miller Fisher syndrome: opthalmoplegia) - Plasmapharesis/IVIG. High dose steroids to start off.
Autonomic involvement: monitor for dysphagia and respiratory function (FVC), spO2
Monitor cardiac function: arrhythmia, hypotenesion
Respiratory support and inotrope support and terminate arrhythmia
On steroid, Fever, headache, middle aged woman. CSF shows high protein, lymphocytosis, low glucose.
1. most likely dx
2. 2 diagnostic tests to confirm dx
3. 2 complications
- Acute TB meningitis
- CSF culture for AFB, TB PCR. Indian ink, fungal PCR to rule out fungal cause
- Acute hydrocephalus (basal meninges adhesion preventing reabsorption of CSF), cerebral infarction (tuberculous arteritis: MCA), CN palsies (3,4,6,7,8), tuberculoma, tuberculous brain abscess
a) Left ischemic stroke affecting the MCA
b) Yes it is within 4.5 hours of onset of symptoms
c) BP measurement (optimize), random blood glucose (optimize)
a) acute tuberculous meningitis
b) culture (ziehl neelson stain), TB PCR
c) hydrocephalus, cerebral infarction, CN palsies (CN 3,4,6,8), tuberculous brain abscess
a) Residual hemiparesis causing uncoordination between leg power.
Parkinsonism features caused by haloperidol (antipsychotic): rigidity, bradykinesia tremor –> susceptible to falls
Oxybutynin is a anticholinesterase (overactive bladder): AE is blurred vision (visual impairment easy to lose balance)
Prochloperazine (dopamine antagonist) used as an antiemetic: produces extrapyramidal symptoms (TRAP), orthostatic hypotension (prone to vasovagal syncope) resulting in falls
b) timed up and go test: patient rises from an arm chair, walks 3m, turns and walks back and sits down again w/o assistance. <10s is normal, >14s increased fall risk, >30s: dependent for ADLs
c)
a. What is the main difference between MCI and mild Alzheimer’s disease?
b. Name 1 drug for mild AD approved by the FDA for Alzheimer’s disease. (1) What is the mechanism?
c. Apart from memory, list two cognitive domains that would be affected in AD.
d. Describe 2 side effects from 2 organ systems
e. Name 1 drug approved by the FDA for moderate to severe AD. (1) What is the mechanism?
a. +/-ADL
b. Rivastigmine: AChE bocker
c. Orientation, attention, language, executive function
d.
e. Memantine: NMDA antagonist
A patient was admitted for emergency surgery at night for sigmoid volvulus. He woke up at 11pm after surgery but with dense right sided hemiplegia. Urgent CT brain at midnight showed dense MCA sign.
a. Can you give IV thrombolysis? Why or why not?
His son is a high court lawyer and demands that you perform urgent reperfusion for him.
b. Are there any other revascularization methods? If no, why not? If yes, what is it and what investigation will you do beforehand
The patient was shown to have transient AF, hyperlipidemia and hyperglycemia.
c. Which of the above conditions predisposed to his stroke?
The patient regains some neurological function and you are discussing pharmacological methods to prevent recurrence of stroke
d. After revascularization, will you give antiplatelet or anticoagulant? Name some examples of the antithrombotic drugs you chose
a. No as he woke up with stroke features so is not definite what time was onset of symptoms (time window for tPA may have passed) + recent major surgery
b. Surgical embolectomy, DSA, coagulation profile
c. AF
d. Anticoagulants: DOAC (dabigatran, edoxaban, rivaroxaban)
A young 20+ year old lady presents with her mother. Her mother describes several episodes of her staring into the distance with focal twitching of the right upper limb. This lasts for several minutes until the patient returns to her normal state. The patient cannot recall the episode, and only recalls feeling slightly dizzy. She has no history of head injury or trauma. She has no focal neurological signs, fever or neck stiffness.
a. What is the clinical diagnosis?
b. What immediate investigations will you perform? Give 3
The patient is sent home after the investigations and is awaiting the results. However, presents again with generalized stiffening, followed by loss of consciousness and generalized convulsions.
c. What is the diagnosis?
d. What drug can you give to prevent the condition happening again?
a. Complex partial seizure. Focal onset, impaired awareness, motor onset seizure
b. EEG, CT brain, serum glucose
c. Complex seizure (partial seizure –> generalized tonic clonic seizure)
d. Valproate
